Diffusion tensor imaging reveals microstructural differences between subtypes of trigeminal neuralgia

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OBJECTIVE

Trigeminal neuralgia (TN) is an uncommon idiopathic facial pain syndrome. To assist in diagnosis, treatment, and research, TN is often classified as type 1 (TN1) when pain is primarily paroxysmal and episodic or type 2 (TN2) when pain is primarily constant in character. Recently, diffusion tensor imaging (DTI) has revealed microstructural changes in the symptomatic trigeminal root and root entry zone of patients with unilateral TN. In this study, the authors explored the differences in DTI parameters between subcategories of TN, specifically TN1 and TN2, in the pontine segment of the trigeminal tract.

METHODS

The authors enrolled 8 patients with unilateral TN1, 7 patients with unilateral TN2, and 23 asymptomatic controls. Patients underwent DTI with parameter measurements in a region of interest within the pontine segment of the trigeminal tract. DTI parameters were compared between groups.

RESULTS

In the pontine segment, the radial diffusivity (p = 0.0049) and apparent diffusion coefficient (p = 0.023) values in TN1 patients were increased compared to the values in TN2 patients and controls. The DTI measures in TN2 were not statistically significant from those in controls. When comparing the symptomatic to asymptomatic sides in TN1 patients, radial diffusivity was increased (p = 0.025) and fractional anisotropy was decreased (p = 0.044) in the symptomatic sides. The apparent diffusion coefficient was increased, with a trend toward statistical significance (p = 0.066).

CONCLUSIONS

Noninvasive DTI analysis of patients with TN may lead to improved diagnosis of TN subtypes (e.g., TN1 and TN2) and improve patient selection for surgical intervention. DTI measurements may also provide insights into prognosis after intervention, as TN1 patients are known to have better surgical outcomes than TN2 patients.

ABBREVIATIONS AD = axial diffusivity; ADC = apparent diffusion coefficient; AUC = area under the curve; DTI = diffusion tensor imaging; FA = fractional anisotropy; MANOVA = multivariate ANOVA; RD = radial diffusivity; REZ = root entry zone; ROC = receiver operating characteristic; ROI = region of interest; TN = trigeminal neuralgia; TN1 = TN type 1; TN2 = TN type 2.

Article Information

Correspondence Parag G. Patil: University of Michigan Medical School, Ann Arbor, MI. pgpatil@umich.edu.

INCLUDE WHEN CITING Published online July 19, 2019; DOI: 10.3171/2019.4.JNS19299.

K.L.C. and E.C.C. contributed equally to this work.

Disclosures Dr. Conrad reports that her mother owns stock in Nevro, a device company that treats chronic back and leg pain.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Imaging and illustration of the trigeminal root. A: Trigeminal root exiting the brainstem and crossing the trigeminal cistern. B: ROIs in the pontine segment of the trigeminal pathway (pink symbols). C: Perspective illustration of the pontine segment with respect to surrounding structures. Illustration courtesy of Megan Foldenauer, Ph.D. Panel C copyright Parag G. Patil. Used with permission. Figure is available in color online only.

  • View in gallery

    Comparison of DTI parameters in the TN and control populations. A: Pontine segment DTI differences between the affected and unaffected sides in TN1 (mean ± SEM) for RD, AD, ADC, and FA. B: Pontine segment DTI ratios between affected and unaffected sides for TN1 (open circles), TN2 (triangles), and control (squares) patient groups. C: ROC curve illustrates the tradeoff between the true-positive rate (TPR) and false-positive rate (FPR) using RDN or ADCN to distinguish TN1 from other patient groups (TN2 or controls). The example operating point (solid circle) is at (0.28, 0.88). Figure is available in color online only

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